Medical Record Retention Policies : An Ehr, And Paper Medical Records

All the patients’ files should be backed up at least on a weekly basis to ensure that none of the information is lost. (HIPAA, 2011) Another way for accountability of the electronic health record is to have each person in the office has a key card or password to access the system. This will allow for the physician to check back and see if anyone is releasing information or making changes that are not authorized. This also allows for physicians to find out who made changes to a patients record if information is inaccurate. (HIPAA, 2011)

In a healthcare world that operates on stringent budgets and margins, we begin to see the need for a higher capacity healthcare delivery system. This in turn puts pressure on the healthcare organizations to ensure higher standards of patient care, and compliance with the reform provisions. However, these are the harsh realities of today’s healthcare environment, a setting in which value does not always equal quality. The use of technology can help to amend some of this by providing higher capacity care without compromising quality; this can be done with the use of such technology as electronic health records (EHRs). This paper will aim to address how EHRs influence healthcare today by expanding upon topics such as funding sources, reimbursement methods, economic factors, socioeconomic factors, business influences, and cost containment.

Other patient information you may find is documentation for any allergies the patient may have. Insurance information will be noted if the patient is covered were you will find the provider, the billing address, and the patient’s policy number. There will be many different forms in this system that are used to document things such as the patient’s family history, diagnostic results, immunization records, past and present medications taken and the effectiveness of them, and of course there will be doctors notes for any office visits and hospitalizations. In the doctors notes and hospitalization notes you will find documentation for medical conditions or diseases the patient may have had in the past or has presently. Last but certainly not least there will be the common release and authorization forms, there may be advanced directives or living wills on file if the patient has completed them and other relevant information that staff and medical facilities may need to provide quality care for the patient. (Whatis.com, 2008).

Electronic health records (EHR) are health records that are generated by health care professionals when a patient is seen at a medical facility such as a hospital, mental health clinic, or pharmacy. The EHR contains the same information as paper based medical records like demographics, medical complaints and prescriptions. There are so many more benefits to the EHR than paper based medical records. Accuracy of diagnosis, quality and convenience of patient care, and patient participation are a few examples of the

Medical records should be organized in an orderly fashion, and all of the information within the record should be legible to the average reader. The information within the medical record must be accurate and corrections should be made and documented correctly. The wording in medical records should be easily understood and grammatically correct. All of these steps are important to remember when maintaining a medical record for future reference, or even legal issues. Discuss and explain the five basic filing

After decades of paper based medical records, a new type of record keeping has surfaced - the Electronic Health Record (EHR). EHR is an electronic or digital format concept of an individual’s past and present medical history. It is the principle storage place for data and information about the health care services provided to an individual patient. It is maintained by a provider over time and capable of being shared across different healthcare settings by network-connected information systems. Such records may include key administrative and clinical data relevant to that persons care under a particular provider. Examples of such records may include: demographics, physician notes, problems or injuries, medications and allergies, vital

Once all medical records have been converted to EMRs, the paper records should be kept in boxes and stored in a safe, secure location to use in case of legal purposes, or in case the EMRs are compromised. Hackers could get in the system and change the information or corrupt the files and render them unusable. The original copies may also be more trustworthy because they were taken when an event occurred. The EMRs could have been changed somehow when they were being converted from the hard copies. It's better to be safe than sorry.

Once a medical record has been transferred into an EMR it can be shredded. Some medical offices chose to keep the records in a secured location. I suppose when it's kept secured it's a back up. But would it really be effective if they didn't change details in it every time a patient visits? some people I suppose shred it because they've used scanners to get all the information from paper to computer.

Along with the new technologies applying in healthcare, the documentation processes and storages also change from paper charts to computer-based electronic health records (EHR). Many healthcare organizations currently maintain patients’ health records in both formats of paper and electronic. The combination is known as hybrid health record system, which is used to assist in different methods that patients’ information is collected. Hybrid health records (HHR) contain specific patients’ health information. HHRs are stored manually and electronically in multiple places. Current patients’ health records usually contain both digital documents and handwritten notes. Patients’ data are electronically stored, such as laboratory, radiology tests,

Patient Care Coordinator faxes medical record authorization(s) and upload the signed authorization(s) to EeMR under the “Consent” folder.

Depending on the medical group of the member the med records are received in a PO Box and are uploaded on to our system to be viewed by our claims department. This process usually takes a couple weeks. As a result, providers’ staff call upset trying to find out where we stand in making a payment on the claims. When a claim is processed correctly it usually not necessary to open the medical records, but when the same claim is sent more then one time due to missing information. We must verify that the missing information has been added the second time around. These errors are usually brought up on a memo called EOB- explanation of benefits. This is usually sent to providers upon their request. They can use that information to appeal with the insurance company of the member.

The Shenandoah Community Health Center (SCHC) located in Martinsburg, WV, began implementing the Electronic Health Records in 2005. One of the goals they had for implementing this system, was to combine separate medical records that were assigned to the same patients ("A West Virginia Health Center Discusses Implementing Electronic Health Records", 2012)

According to CMS rules, Medicare beneficiaries’ paper health records cannot be destroyed. They can only be eliminated if there are certified digital copies available electronically. The imaged records of the paper form must be exactly replicated and the steps of scanning the original documents into digital format must be detail noted. The healthcare organizations and providers must keep the digital documents in readable conditions that allow easy access. Also, the digital copies must be tamper proofed from editing or manipulating. CMS requires patients’ records, which were submitting for reimbursements by providers, to be kept in their original or legally replicated forms for five years after the closure of the reimbursements. Moreover, CMS

Paper Health Record is patient health information stored and accessed in paper format. It includes the processes of maintaining and storing physical or hard-copy documents. Paper Health Record request no logins to access patient information. Likewise, in paper health record physicians, nurses, or medical receptionist can update the patient file in certain sections easily.

“an electronic version of a patients medical history, that is maintained by the provider over time, and may include all of the key administrative clinical data relevant to that persons care under a particular provider, including demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports (CMS)”